Operative Technique in Plastic Surgery – Kevin C.Chung

71
CHAPTER
Management of Mandibular
Coronoid Fractures
Raja Naddaf
DEFINITION
■ Mandibular coronoid process fracture is extremely uncommon. In the
anatomical distribution of mandibular fractures, coronoid process fractures
account only for 0.2% to 2% of all mandibular fractures.1–3
PATHOGENESIS
■ Etiology of coronoid fractures: motor vehicle accidents, interpersonal
violence, sport injuries, and falls. Less commonly, fractures are caused during
mandibular third molar extraction and bad split during mandibular sagittal split
osteotomy.1–3
ANATOMY
■ The zygomatic arch protects the coronoid process along its lateral aspect. The
temporalis muscle attaches to the lateral surface of the coronoid process.
■ Fracture of the zygomatic arch with medial displacement of fragments can
often impinge on the coronoid process of the mandible and cause trismus.1,3,4
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Clinical exam demonstrates several symptoms, most commonly a limitation in
mouth opening and in lateral movement of the mandible.
■ In some cases, swelling and hematoma can be present; occlusion disturbance
is less common and is usually related to other mandibular fractures.1,3,4
IMAGING
■ Plain radiographs or panoramic radiographs can be helpful, but the standard is
computed tomography (CT) scans (FIG 1).

DIFFERENTIAL DIAGNOSIS
■ Considering anatomical and functional relations, when facing a coronoid
process fracture, the surgeon must take into consideration the probability of
concomitant zygomatic arch fracture.
NONOPERATIVE MANAGEMENT
■ Treatment of coronoid process fractures can be divided into three categories:
■ Nonoperative management
■ Conservative treatment
■ Open reduction and internal fixation (ORIF)
■ Nonoperative management is advocated in cases of minimally displaced
coronoid process fractures, absence of mouth opening limitation or trismus,
and usually when the fracture is solitary.
SURGICAL MANAGEMENT
■ In cases of concomitant zygomatic arch fractures, one should consider closed
reduction of the arch fracture only.
■ Several authors advocate the removal of the fractured coronoid process via an
intraoral incision (coronoidectomy) in order to prevent fibrosis or ankylosis
between the coronoid and the surrounding structures.1,3,4
■ ORIF is indicated in cases of significant displacement of the coronoid process
or when there are other associated mandibular fractures (body, angle, condylar
process).1,3,4
■ In cases of multiple mandibular fractures, there is an indication for ORIF of
the coronoid fracture.
PREOPERATIVE PLANNING
■ Imaging to visualize the coronoid fracture can be either x-rays, including
panoramic radiography, or CT scans.
POSITIONING
■ Nasal intubation is the preferred method, unless there are contraindications
due to midface fractures or the need for tracheostomy.
■ The patient should be placed in the supine position, with the head on a
headrest to enable head manipulation during the operation.
APPROACH
■ ORIF can be performed via an intraoral approach (less favored) or a modified

retromandibular approach or via submandibular approach through a Risdon
incision (more favored).
FIG 1 • Coronoid fracture as shown on sagittal (A),
coronal (B), and axial (C) CT scans. D. 3D
reconstruction demonstrates a coronoid fracture with a
concomitant zygomatic complex fracture.
T E C H N I Q U E S
■ ORIF via Modified Retromandibular Approach
■ Begin by marking the inferior border of the mandible.
■ The skin incision should be 2 cm inferior to the lower border of the
mandible (or two fingerbreadths).
■ The lips should be exposed to see if the marginal mandibular nerve is
stimulated during dissection.

■ Vasoconstrictor with lidocaine can be injected subcutaneously but not deep
to the platysma so the marginal mandibular branch is not anesthetized.
■ The incision can be extended according to the location of the fracture.
Posteriorly, it can be extended to the mastoid.
■ The incision is extended to the platysma. Then blunt dissection should be
performed through the platysma and to the superficial layer of deep
cervical fascia. This dissection should be extended to the full extent of the
skin incision (TECH FIG 1A,B).
■ Avoid injury to the marginal mandibular branch of the facial nerve, which is
usually inferior to the lower border of the mandible and superficial to the
facial artery and vein.
■ The facial artery and vein can be ligated, and once retracted superiorly, this
ensures protection of the marginal mandibular branch (TECH FIG 1C).
■ Continue the dissection until reaching the pterygomasseteric sling and then
make a sharp incision through the sling.
■ Subperiosteal dissection is performed on the lateral surface of the body and
ramus of the mandible and superiorly toward the coronoid process of the
mandible (TECH FIG 1D).
■ When exposing the fractured coronoid process, anatomical reduction and
fixation is done by appropriate plates and screws.
■ Usually, two 2.0 miniplates are needed (conventional mandibular plates);
when the reduction is gained, use a 1.5-mm drill and 2-mm screws.
■ At least two screws are required on each side of the fracture line.
■ In some cases, a single miniplate is sufficient to properly reduce the
fracture.
■ After completing ORIF, ensure hemostasis.
■ Close by approximating the pterygoid and the masseter muscles, preferably
with continuous resorbable sutures.
■ Continue suturing the superficial layer of the deep cervical fascia and the
platysma.
■ Close the skin incision with interrupted nylon sutures. These sutures are to
be removed after 7 days.
■ Directions for wound care management are given prior to patient’s
discharge.

TECH FIG 1 • A. Hemostats have been used to bluntly
dissect under the platysma. With the hemostats in
place, the platysma is divided sharply. B. The
marginal mandibular branch of the facial nerve is
superficial to the facial artery and vein. C. After
dissection through the superficial layer of the deep
cervical fascia, the facial artery and vain are ligated
and retracted superiorly. Then sharp dissection is
performed on the pterygomasseteric sling. D.
Subperiosteal dissection on the lateral surface of the
body and ramus of the mandible and superiorly to the
coronoid process.
■ Coronoidectomy by an Intraoral Approach
■ Infiltrate lidocaine with vasoconstrictor.
■ Make a vestibular incision through the mucosa, keeping a distance of 5 mm
from the mucogingival line (TECH FIG 2A).

■ Extend the incision to the external oblique ridge.
■ Expose the ramus and the angle of the mandible with subperiosteal
dissection (TECH FIG 2B).
■ The coronoid process is usually located in a more coronal position, because
of persistent temporalis muscle attachments.
■ After exposing part of the coronoid subperiosteally, grasp the coronoid with
a large hemostat and pull while dissecting the coronoid subperiosteally until
it is free from soft tissue.
■ To close, suture the soft tissue with continuous resorbable sutures.
TECH FIG 2 • A. The vestibular incision is extended
superiorly to the ascending ramus. B. Subperiosteal
exposure of ascending ramus, lateral surface of the
mandible, and the coronoid.
PEARLS AND PITFALLS
Physical
findings
■ Most coronoid fractures are treated conservatively.
■ When a coronoid process fracture is present, consider the presence
of associated zygomatic arch fractures, mandibular ramus, or body

fractures.
Technique
■ A proper extraoral dissection using an electric nerve detector can
aid in minimizing injury to the marginal mandibular branch of the
facial nerve.
Postoperative
■ Short- or long-term limitation of mouth opening can be managed
with physiotherapy.
POSTOPERATIVE CARE
■ Antibiotics and corticosteroids can be administered.
■ Soft diet should be given for the first few days after the operation.
■ Chlorhexidine-containing mouthwash is used for 2 weeks.
■ Postoperative panoramic and submentovertex x-rays can be performed
postoperatively.
■ If limitation of mouth opening is persistent 2 weeks postoperatively, the
patient should receive physiotherapy.
OUTCOMES
■ Patients with isolated coronoid fractures should generally have no long-term
sequelae.
■ Complications are much more likely to result from other associated facial
fractures.
COMPLICATIONS
■ Hematoma
■ Limitation of mouth opening
■ Trismus
■ Wound infection
■ Extraoral scars
■ Malunion
■ Nonunion
■ Infection due to loose hardware
■ Damage to the marginal mandibular branch of the facial nerve
REFERENCES
1. Gadicherla S, Sasikumar P, Gill SS, et al. Mandibular fractures and associated
factors at a tertiary care hospital. Arch Trauma Res. 2016;5(4):e30574.
2. Ruslin M, Boffano P, ten Brincke YJ, et al. Sport-related maxillo-facial

fractures. J Craniofac Surg. 2016;27:e91-e94.
3. Boffano P, Kommers SC, Roccia F, et al. Fractures of the mandibular coronoid
process: a two centres study. J Craniomaxillofac Surg. 2014;42:1352-1355.
4. Kisnisci R. Management of fractures of the condyle, condylar neck, and
coronoid process. Oral Maxillofacial Surg Clin North Am. 2013;25:573-590.

72
CHAPTER
Surgical Correction of
Nonunion of Mandible
Fracture
Howard D. Wang, Arthur J. Nam, and Amir H. Dorafshar
DEFINITION
■ Nonunion of a mandible fracture occurs when there is a failure of the fracture
to heal within an adequate amount of time.
■ Nonunion of a mandible fracture usually leads to pain, malocclusion, and
inability to masticate.
■ Haug and Schwimmer defined this time period as 8 weeks after surgical
management or 4 weeks without treatment.1
■ Mandibular nonunions are uncommon complications after mandible fractures
with a reported incidence of 2.8% to 3.9%.1–3
ANATOMY
■ The mandible consists of two hemimandibles fused at the midline symphysis,
and injuries can be classified based on the location of the fracture.
■ The most common location of nonunion is the body, followed by the angle
region of the mandible.2
PATHOGENESIS
■ Nonunion of mandible fractures generally occurs as a result of inadequate
fracture stabilization, inaccurate reduction, infection, or delayed treatment.
■ Other risk factors associated with nonunion include injury characteristics, such
as teeth in the fracture line or presence of multiple mandible fractures, and
patient characteristics such as edentulous mandible, tobacco use, alcohol abuse,
immune deficiency, diabetes mellitus, or patient noncompliance.2
PATIENT HISTORY AND PHYSICAL FINDINGS

■ History
■ A thorough history should include the patient’s chief complaint and
symptoms such as pain, trismus, fever, and drainage.
■ Reviewing all preoperative, intraoperative, and postoperative data from
previous surgical treatments related to the initial mandibular trauma is critical
in identifying the etiology of nonunion.
■ Patient comorbidities including diabetes mellitus, immunosuppression, or
polysubstance abuse should be elicited as these factors can contribute to the
ultimate outcome.
■ Physical examination
■ Patient’s facial height, width, and symmetry are assessed.
■ The mandible is palpated for tenderness, bony deformities, presence of
abscess, and instability.
■ Intraoral examination is performed with a focus on the occlusion, dental
decay, oral hygiene, presence of purulent drainage, and condition of the oral
mucosa.
■ Any existing deficits in the sensory distribution of the inferior alveolar nerve
and motor innervation of marginal mandibular branch of facial nerve are
documented.
IMAGING
■ Plain x-ray films (facial series, panoramic) can be used for postoperative
evaluation to identify an enlarging gap in the fracture line, presence of irregular
radiolucency, and/or hardware loosening (FIG 1A, B).
■ Maxillofacial computed tomography (CT) with three-dimensional formatting
has become the imaging modality of choice for evaluation of the fracture site,
extent of soft tissue infection, and associated osteomyelitis (FIG 1C–F).
NONOPERATIVE MANAGEMENT
■ Mandibular nonunions are often associated with infections of the soft or bony
tissue, which require antibiotic therapy.
■ Choice of antibiotics should focus on coverage of Gram-positive and
anaerobic organisms with subsequent culture-directed antibiotics.

FIG 1 • A. Immediate postoperative panoramic plain
radiograph after ORIF of multiple mandible fractures. B.
Follow-up panorex demonstrating hardware loosening
and nonunion of the left mandibular angle fracture. C. A
3D reconstruction of CT images demonstrating right
parasymphyseal fracture immediately after open
reduction and internal fixation. D. Repeat CT imaging
showing evidence of nonunion at 4 weeks after surgery.
E. Soft tissue window revealing evidence of abscess

formation near the site of the nonunion. F. Bone window
showing the presence of bone gap.
■ The duration of treatment will depend on whether the infection affects the soft
tissue alone or if osteomyelitis is present, which may require 4 to 6 weeks of
intravenous treatment.
SURGICAL MANAGEMENT
■ The general algorithm for management of nonunion of mandible fractures
includes debridement of nonviable bone to establish fresh bony edges, bone
grafting when there is a lack of bone-to-bone contact, and rigid fixation to
achieve proper stabilization.
■ Occlusion should first be established with maxillomandibular fixation (MMF).
It is important to ensure that the condyles are well seated superiorly in the
glenoid fossa.
■ Although the presence of infection does not always necessitate removal of
existing hardware, mandibular nonunions generally result due to inadequate
stabilization, and existing hardware will usually need to be removed.
■ Any evidence of hardware loosening or fracture instability is a clear
indication for hardware removal.
■ Debridement of devitalized or infected bone back to healthy, bleeding bone is
critical for both clearance of infection and achieving bony union.
■ Teeth in the line of fracture should be extracted, especially in the presence of
infection.4
■ A bone biopsy should be performed to diagnose and guide treatment of
osteomyelitis.
■ Traditionally, management of infected mandibular nonunions was performed
with prolonged MMF or external fixation to control occlusion while the
infection is treated and the soft tissue is healing. This was done to avoid
placement of hardware in an infected field.5
■ More recent work suggests that instability is a primary contributor to the
development of infected mandible fractures and that the use of rigid internal
fixation after adequate debridement is a viable treatment option to achieve
resolution of infection and bony union.6
■ Therefore, rigid internal fixation has become the preferred method and should
be performed using a load-bearing reconstruction plate with at least three

bicortical locking screws on each side of the fracture.
■ The closest screw should be placed at a minimal distance of 7 to 10 mm from
the fracture edge.7
■ If the bone gap is small, bony union can be achieved with improved rigid
fixation. However, larger gaps with inadequate bone contact will require
autogenous bone grafting.
■ Cancellous bone grafts packed tightly into the defect area have a high success
rate by improving osteogenic potential.8
■ Vascularized bone flaps (with or without associated skin paddle) are indicated
in cases where a critical-sized defect greater than 6 cm is present, when
previous bone grafting has failed, or when severe soft tissue contracture is
present.9
■ Potential options include free fibula flap or deep circumflex iliac artery
(DCIA) flap.
■ The choice of donor site depends on the location and size of the mandibular
defect.
■ The DCIA flap is often preferred for mandible defects involving the
dentoalveolar region because it provides ample bone stock for
osteointegrated dental implants, and the fibula flap is preferred for long
defects or when multiple osteotomies are required, such as for anterior
mandible defects.10
■ There are two schools of thought in terms of timing of reconstruction.
■ The delayed approach involves treatment of infected mandible with long-term
antibiotics (6 weeks) after debridement to allow for resolution of infection and
healing of intraoral incisions and teeth extraction sites. Repeat imaging can
then be obtained to ensure there is no evidence of infection. Autogenous bone
grafting is then performed as a second stage.
■ More recently, Alpert popularized the immediate approach in which
autogenous bone graft is performed at the time of initial debridement.11 The
major advantage of this approach is avoiding a subsequent operation; however,
soft tissue closure may be more challenging in these circumstances.
Preoperative Planning
■ Careful review of imaging is performed to assess the need for teeth extraction
and the extent of bony debridement.
■ The need for autogenous bone graft or vascularized bone flaps is determined

prior to the operation.
Positioning
■ The patient is positioned supine with nasotracheal intubation, so proper
occlusion can be checked intraoperatively.
■ If an iliac crest bone graft is needed, a bump should be placed under the
gluteal region to elevate the iliac crest, and the lateral hip area should be
prepped.
Approach
■ Surgical management of mandibular nonunion can be performed via either an
external transfacial approach or an intraoral approach.
■ The major advantages of the intraoral approach are avoidance of an external
scar and risk of injury to the marginal mandibular branch of the facial nerve.
■ However, the intraoral approach alone should be attempted only if there is
sufficient healthy oral mucosa tissue for closure after debridement and
fixation.
■ Otherwise, an external approach is usually preferred after the intraoral wound
has healed to avoid intraoral contamination of the surgical site. Furthermore, an
external approach provides wide exposure for direct visualization of the
fracture site, for obtaining sterile cultures, and for easier placement of
bicortical screws while avoiding injury to the inferior alveolar nerve.
■ The Risdon (submandibular) approach is frequently used to gain access to the
body or angle region.
T E C H N I Q U E S
■ Single-Stage Operation With Iliac Crest Bone
Grafting via an Intraoral Approach
■ Loose teeth within the fracture line are extracted (TECH FIG 1A).
■ An intraoral incision is made to expose the fracture segment.
■ Debridement of all nonviable bone is performed, usually with a cutting
rotating bur.
■ Patient’s premorbid occlusion is then established with MMF.

■ With the condyles seated properly in the glenoid fossa, the fracture segments
are then placed into rigid fixation.
■ In this case, a Champy plate and a lower border plate were applied (TECH
FIG 1B).
TECH FIG 1 • A patient presented with a left
mandibular angle fracture 4 weeks after initial injury.
A. Maxillofacial CT demonstrating a nonunion of the
left mandible angle fracture with the presence of a
loose molar in the fracture line. B. Postoperative CT
showing rigid fixation of the fracture with Champy
plate and lower border plate. C. CT showing
cancellous bone graft packed into the fracture gap.
■ Three locking bicortical screws are inserted on each side of the fracture
line to secure the lower border plate.
■ Autogenous bone graft may be required in cases where a bone gap exists

after debridement of unhealthy bone at the site of the nonunion and can be
harvested from a number of donor sites including the iliac crest, anterior
tibia, or calvarium.
■ The authors’ preferred donor site is the iliac crest.
■ Once sufficient cancellous bone graft material has been harvested, it is
packed tightly into the bone gap (TECH FIG 1C).
■ The intraoral incision is then closed tightly with absorbable sutures.
■ Two-Stage Operation With Osseous Free Flap
■ The goal of the first stage is to remove all nonviable bone and allow healing
of the intraoral soft tissue (TECH FIG 2A).
■ Reconstruction of the mandible is performed in a subsequent operation via
an external approach.
Stage 1: Debridement of Nonviable Bone and MMF
■ Debridement of all nonviable bone is performed via an intraoral approach
(TECH FIG 3).
■ Patient’s premorbid occlusion should be established with MMF.
■ The intraoral wound is then allowed to heal over the course of 6 to 8 weeks.
Stage 2: Vascularized Free Osseous Flap Reconstruction via
a Risdon Approach
■ An osseous free flap such as the free fibula or DCIA flap may be required in
cases when the size of the mandibular defect exceeds 6 cm.
■ A two-team approach should be used whenever possible to reduce operative
time.
■ An external incision is made in a relaxed skin tension line approximately 2
cm caudal to the inferior border of the mandible. The length of the incision
depends on the extent of the fracture (TECH FIG 4A).
■ The platysma is divided after incision through the skin and the subcutaneous
tissue (TECH FIG 4B).
■ The marginal mandibular branch of the facial nerve lies deep to the platysma
and may lie up to 2 cm below the ramus of the mandible; therefore, the
platysma should be incised at least 2 to 3 cm below the inferior border of the
mandible to avoid nerve injury.

TECH FIG 2 • A patient presented with nonunion of
the left mandibular body fracture 8 weeks after open
reduction and internal fixation at an outside facility.
Because of the significant intraoral soft tissue
deficiency, a two-stage treatment plan was selected.
A. CT demonstrating evidence of nonunion of the left
mandibular body after previous fixation. B. Exposed
left mandible fracture with significant intraoral soft
tissue deficiency.
TECH FIG 3 • Nonviable bone is removed using the
existing intraoral exposure.
■ The facial vessels lie deep to the marginal mandibular nerve in a
craniocaudal direction. The vessels are ligated and reflected superiorly to
protect the marginal mandibular nerve in the superior flap (TECH FIG 4C).
■ The inferior border of the mandible is exposed by dividing the

pterygomasseteric sling and incising through the periosteum (TECH FIG
4D).
■ Any unhealthy bone should be removed, and the fracture edges are burred
until new bleeding edges are visualized (TECH FIG 4E).
■ The recipient vessels should be identified in the neck for microvascular
anastomosis. Options include the facial vessels, superior thyroid vessels,
external carotid artery, and external and internal jugular veins.
■ A DCIA flap is harvested along with a cuff of the internal oblique muscle
(TECH FIG 4F).
■ Once the flap has been harvested, a reconstruction plate is then adapted and
applied to the bone flap.

Platysma muscle Facial artery and vein Marginal mandibular nerve Masseter muscle

TECH FIG 4 • A. Risdon (submandibular) approach to
the mandible. The skin incision is made approximately
2 cm caudal to the inferior border of the mandible. B.
The platysma muscle is then divided at 2 to 3 cm
below the inferior border of the mandible. C. The facial
artery and vein are identified and ligated. The
marginal mandibular branch of the facial nerve runs
superficial to the facial vessels. Reflecting the ligated
facial vessels superiorly protects the nerve in the
superior flap. D. Incision through the
pterygomasseteric sling and the periosteum to expose
the inferior border of the mandible. E. Excision of any
remaining unhealthy bone. F. DCIA bone flap is
harvested with a cuff of the internal oblique muscle. G.
Flap inset into the defect and fixation with a
reconstruction plate. H. Six-month postoperative CT
demonstrating bony union.
■ Flap inset is then performed with three locking screws placed on either side
of the defect (TECH FIG 4G).
■ Unicortical screws should be used on the flap to avoid injury to the
vascular pedicle.
■ Next, the microvascular anastomosis is performed to the recipient vessels.
■ Closure of the incision should be performed in layers, approximating the
pterygomasseteric sling, platysma, and skin. A suction drain can be left

depending on surgeon preference.
■ Successful bony union can be seen on a follow-up CT scan (TECH FIG
4H).
PEARLS AND PITFALLS
Debridement
■ Aggressive debridement of pseudoarthrosis or infected bone stock
is necessary for bony union.
Fixation
■ Rigid fixation with load-bearing construct is necessary to improve
the chances of union.
Timing of
bone grafting
■ Primary bone grafting can often be performed at the time of
debridement.
■ If there is concern about the quality of soft tissue, bone grafting
can be delayed and performed at a later stage.
POSTOPERATIVE CARE
■ A 4 to 6-week course of postoperative antibiotics is usually administered for
treating osteomyelitis.6
■ The decision for use of postoperative MMF after rigid fixation is frequently
surgeon-dependent.
■ Although some surgeons advocate that MMF is not required with rigid
fixation, others prefer short-term (1 to 2 weeks) fixation with wires or elastics.
■ The patient is started on a liquid or wired-jaw diet and progressed to a soft
diet.
■ Early physiotherapy is initiated to maintain maximum interincisal jaw opening
and avoid complications of ankylosis of the temporomandibular joint.
■ Patients with intraoral wounds are instructed to use chlorhexidine oral rinses at
least 3 times a day.
OUTCOMES
■ Studies on mandibular fracture nonunions are limited to small case series with
short follow-up time.
■ Benson and Alpert11 retrospectively reviewed 43 patients with 50 infected
mandibular fractures who were managed with debridement, rigid internal

fixation, and immediate autogenous particulate bone grafting.
■ They reported that 94% achieved bony union and 86% required only one
operation.
■ Mehra et al.7 retrospectively reviewed 44 patients with infected mandibular
fractures and divided them into those with soft tissue infection vs
osteomyelitis.
■ Their treatment protocol of incision and drainage, debridement, fracture
reduction, and stabilization with rigid internal fixation achieved 100% success
rate for soft tissue–infected mandibular fractures and 92% success for those
with osteomyelitis.
■ Yamamoto et al.12 reported that only 1 of 10 patients with mandible nonunion
who were treated with removal of hardware and new fixation with 2.4-mm
reconstruction plate required an additional operation to achieve union.
COMPLICATIONS
■ Recurrent infection (ie, osteomyelitis)
■ Nonunion
■ Malunion
■ Facial nerve injury (marginal mandibular branch) with external incision
■ Inferior alveolar nerve injury
■ Malocclusion
■ Scarring
■ Hardware exposure
■ Trismus
REFERENCES
1. Haug RH, Schwimmer A. Fibrous union of the mandible: a review of 27
patients. J Oral Maxillofac Surg. 1994;52:832-839.
2. Mathog RH, Toma V, Clayman L, Wolf S. Nonunion of the mandible: an
analysis of contributing factors. J Oral Maxillofac Surg. 2000;58:746-752.
3. Bochlogyros PN. Nonunion of fractures of the mandible. J Maxillofac Surg.
1985;13:189-193.
4. Koury M, Ellis E III. Rigid internal fixation for the treatment of infected
mandibular fractures. J Oral Maxillofac Surg. 1992;50:434-443.
5. Alpert B, Kushner GM, Tiwana PS. Contemporary management of infected
mandibular fractures. Craniomaxillofac Trauma Reconstr. 2008;1:25-29.
6. Koury ME, Perrott DH, Kaban LB. The use of rigid internal fixation in

mandibular fractures complicated by osteomyelitis. J Oral Maxillofac Surg.
1994;52:1114-1119.
7. Mehra P, Van Heukelom E, Cottrell DA. Rigid internal fixation of infected
mandibular fractures. J Oral Maxillofac Surg. 2009;67:1046-1051.
8. Bruno JR, Kempers KG, Silverstein K. Treatment of traumatic mandibular
nonunion. J Craniomaxillofac Trauma. 1999;5:27-32.
9. Yokoo S, Komori T, Sakurai A, et al. Therapeutic importance of
transplantation of a vascularised free flap for an oromandibular injury with
infection and severe scar contracture. Br J Oral Maxillofac Surg. 2003;41:380-
382.
10. Schultz BD, Sosin M, Nam A, et al. Classification of mandible defects and
algorithm for microvascular reconstruction. Plast Reconstr Surg.
2015;135:743e-754e.
11. Benson PD, Marshall MK, Engelstad ME, et al. The use of immediate bone
grafting in reconstruction of clinically infected mandibular fractures: bone
grafts in the presence of pus. J Oral Maxillofac Surg. 2006;64:122-126.
12. Yamamoto MK, D’Avila RP, Luz JG. Evaluation of surgical retreatment of
mandibular fractures. J Craniomaxillofac Surg. 2013;41:42-46.

73
CHAPTER
Section XII: Panfacial
Trauma
Surgical Correction of
Panfacial Fractures
Detlev Erdmann and David Powers
DEFINITION
■ The facial skeleton is composed of four subunits: frontal, upper midface, lower
midface, and mandible.
■ Panfacial fractures are defined as any fracture pattern that involves at least
three of these four segments.1
ANATOMY
■ The face consists of 14 bones, 12 of which are paired (inferior nasal concha,
lacrimal bones, nasal bones, maxillae, palatine bones, zygomatic bones) and 2
of which are not (mandible and vomer).
■ The frontal bone constitutes the major component of the forehead and forms
the superior part of each orbital rim.
■ Zygomatic process of the frontal bone projects inferiorly to form the upper
lateral orbital rim.
■ The zygomatic bone forms the lower lateral and part of the inferior orbital rim.
■ Malar surface: Convex shape, contains the zygomaticofacial foramen
■ Temporal surface: Concave, articulates with maxilla (articular surface) and
contains the zygomaticotemporal foramen
■ Orbital surface: Contains the zygomatic orbital foramen
■ The nasal bones articulate with each other at midline as well as the frontal
bone superiorly and the frontal process of the maxillary bone laterally.

■ Maxillae lie in between the orbit and the upper teeth and consist of a body,
zygomatic process, frontal process, alveolar process (contains the teeth of the
upper jaw), palatine process (forms 75% of the hard palate), infraorbital
foramen, and maxillary sinus.
■ Forms the inferior and medial orbital rims
■ Articulates with the frontal, zygomatic, ethmoid, nasal, and lacrimal bones
■ The mandible consists of a body (anterior) and ramus (posterior).
■ The body of the mandible is further subdivided into the base and the alveolar
portion, which contains the teeth of the lower jaw.
■ The ramus consists of two clinically significant superior projections:
• The more posterior projection is called the condyle (which contributes to the
formation of the temporomandibular joint).
• The more anterior projection is called the coronoid process (which is the site
of attachment for the temporalis muscle).
PATHOGENESIS
■ Facial fractures occur in the setting of trauma, with assault and motor vehicle
collisions (MVC) as the most common etiologies (36% and 32%, respectively,
of all facial fracture cases presenting to a representative US institution).1
■ MVC and gunshot wounds (GSW) have been specifically shown to be
significant predictors of panfacial fracture patterns.1
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Once the patient has been appropriately stabilized, obtaining as complete a
history as possible is integral to assess for specific injury patterns even prior to
performing imaging studies.
■ The following questions are most important when performing a systematic
exam of the patient:
■ How and when did the accident occur?
■ What are the specifics of the injury?
■ What symptoms does the patient currently have (pain, altered sensorium, loss
of consciousness, malocclusion)?
■ Certain subjective complaints can substantiate the presence of specific
craniomaxillofacial injuries; for example, new-onset anesthesia of the
cheek/maxillary teeth may be a result of zygomaticomaxillary fractures
resulting in injury of the infraorbital nerve.
■ Physical examination

■ Cranium/cranial base: Note any lacerations, swelling, ecchymoses, and
contour irregularities.
■ Frontal region: Inspect for any lacerations, depressions, or crepitus.
■ Orbits: Examine for edema, ecchymoses, enophthalmos (possible
zygomaticomaxillary complex fractures), emphysema, and limited upward
gaze (possible inferior rectus muscle entrapment).
■ Nasal region: Check for signs of naso-orbital-ethmoid (NOE) fracture, such
as septal deviation or hematoma and telecanthus.
■ Maxillary region: Assess for infraorbital nerve paresthesia or malar
depression, trismus secondary to impingement on the coronoid process, and
maxillary mobility.
■ Ear region: Examine for hematoma and integrity of auditory canal/tympanic
membrane.
■ Mandible: Note the presence of external lacerations, ecchymosis or gingival
tears (a possible sign of mandibular body or symphyseal fracture), step-off
deformities, paresthesia along the distribution of the inferior alveolar nerve
(an indication of fractures distal to mandibular foramen), periauricular pain,
or malocclusions.
■ Additionally, a thorough intraoral, ocular, and neurological exam should be
conducted to rule out dental malocclusions, ophthalmological emergencies, and
focal neurological defects.
IMAGING
■ Computed tomography (CT) has largely replaced other imaging modalities as
the standard for evaluation of facial trauma.
■ Axial, coronal, and sagittal cuts are utilized to visualize specific fracture
patterns and reformatted to generate three-dimensional (3D) images (FIG
1A–C).
■ A standard head CT is better used as a screening tool, given its limited ability
to visualize the zygomatic arch as well as the complete maxilla and mandible
(FIG 1D,E).
■ A more complete craniomaxillofacial CT should extend from the vertex of
the skull to the symphysis of the mandible.
■ 3D CT imaging affords additional understanding of the spatial relationship of
fracture fragments but does not provide information about soft tissue
deformities.

NONOPERATIVE MANAGEMENT
■ Although most panfacial fractures are severe enough to warrant surgical
treatment, facial fractures that are stable, nondisplaced, or asymptomatic may
be managed conservatively with follow-up.2
FIG 1 • A. Axial CT imaging can be used to visualize
specific fracture patterns. B,C. CT imaging can be
reformatted into three-dimensional images that are
useful for preoperative planning. D. Craniomaxillofacial
CT imaging provides a more comprehensive view of the
zygomatic arch as well as the maxilla and mandible. E.
Comminuted midface fractures.
SURGICAL MANAGEMENT
■ The primary goal of panfacial trauma management is to establish an
anatomically reduced platform from which to base the remainder of the
reconstruction.

Preoperative Planning
■ Review of preoperative radiographs with 3D reconstruction is necessary.
■ Written sequencing of surgical approaches and goals for each section
■ Confirmation of necessary surgical instrumentation and plating hardware to
reconstruct the defects
Positioning
■ The patient should be prepared and draped widely to allow for any and all
needed exposures.
■ A horseshoe head frame may be used for coronal exposure.
Approach
■ One of the more common techniques for addressing midfacial fractures, often
referred to as “outside-in” technique, focuses on first repairing the zygomatic
arch to correct facial width.
■ Zygomaticomaxillary complex fractures are usually repaired with open
reduction and internal fixation.3
■ The “bottom-to-top” approach focuses on reconstruction of the mandible first
—generally accomplished as the mandibular bone is less prone to comminution
in most causes of panfacial trauma—which results in larger bone fragments
that are technically easier to repair.
■ The “top-to-bottom” approach initiates repair at the forehead before working
down to the maxilla and mandible (FIG 2).
■ This approach focuses on reconstruction of the “outer facial frame.” The
orbital rims are used as a landmark to align the nasofrontal structure before
reduction of the zygomatic arches and realignment of the maxilla and
mandible.4,5
■ The “bottom-to-top-to-middle” approach focuses on reconstruction of the
mandible first—generally accomplished first because the mandibular bone is
less prone to comminution in most etiologies of panfacial trauma—which
results in larger bone fragments that are technically easier to repair.
■ Attention is then directed toward the zygomatic arches/frontal bar regions
and the NOE/orbit, correcting any discrepancy at the Le Fort I level as the
final intervention.
■ Possible incisions for gaining access to the mandible include the following:
■ Anterior degloving (FIG 3A)

■ Intraoral degloving (FIG 3B)
■ Posterior degloving (FIG 3C)
■ Hinds incision/posterior ramus approach (FIG 4)
■ Preauricular incision (FIG 5)
■ Risdon incision (FIG 6)
■ Submental incision (FIG 7)
■ Transcervical incision (FIG 8)
FIG 2 • The “outside-in” technique focuses on repairing
the zygomatic arch first in order to correct facial width.

FIG 3 • Anterior (A), intraoral (B), and posterior (C)
degloving incisions are made about 3 to 5 mm above
the mucogingival junction and carried down through the
mucosa, submucosa, facial muscles, and periosteum.

FIG 4 • The Hinds incision is particularly helpful for
injuries involving the ramus, neck, or head of the
mandible. Avoid the superior and inferior divisions of
the facial nerve as well as the retromandibular vein. The
incision can be made parallel to the ramus or over the
posterior border of the ramus toward the mandibular
angle.

FIG 5 • Preauricular incisions can be utilized to expose
the TMJ. Given the location of the superficial temporal
vessels and the auriculotemporal nerve relative to the
TMJ, injury to these structures is possible and must be
avoided. The incision is made to the superficial layer of
the temporalis fascia. An anterior flap is then raised
above the zygomatic arch and the superficial layer of
the temporalis fascia is incised. The periosteal elevator
is then shifted posteriorly and incised vertically.
Retraction will then expose the TMJ capsule.
FIG 6 • A. The Risdon incision can be used to expose
the mandibular angle, ramus, condyle, and TMJ. The
incision is made 2 cm inferior and parallel to the inferior
border of the mandible of the neck and to the level of

the platysma. B. Dissection is continued to the deep
cervical fascia and submandibular salivary gland, with
eventual incision of the superficial layer of the deep
cervical fascia. Great care must be taken to avoid injury
to the facial artery and vein as well as the marginal
mandibular branch of the facial nerve. C. During
anterior dissection, the mental nerve must be avoided.
FIG 7 • The submental incision, used in repair of
mandibular symphysis fractures, can be made to follow
the anterior curve of the mandible or can be hidden
within a skin crease. The incision is made to the
platysma. Dissection is carried out to the inferior border
of the mandible and the periosteum is incised sharply.

FIG 8 • A. The transcervical incision is made above the
thyroid cartilage from the midline toward the angle of
the mandible bilaterally and carried down to the
superficial layer of the deep cervical fascia. B. A flap is
then raised toward the inferior border of the mandible
anterolaterally. Identify the cervical and mandibular
branches of the facial nerve as well as the facial artery
and vein to avoid injury. The periosteum is then incised
at the inferior border of the mandible from midline to the
mandibular angle bilaterally.
T E C H N I Q U E S
■ Bottom-to-Top Approach
■ Erich arch bars are adapted to the maxilla and mandible and secured with 24-
gauge stainless steel wires.

Video p2-c073_01
■ Placement of the arch bars should only begin on one side and progress
laterally by incorporating all of the dentition.
■ The arch bars are malleable, and simultaneous placement of the arch bars
from the bilateral posterior region results in “excess” material, which
classically prevents incorporation of the anterior dentition.
■ Bone-anchored arch bars can be considered for dental arches that do have?
disruption of the dentoalveolar tables (TECH FIG 1A,B).
00:00 / 00:00

TECH FIG 1 • A. Preoperative appearance. B. Arch
bar placement. C. Resuspension of soft tissue. D.
Closure of incisions.
■ Access to the mandible is achieved with a combination of a no. 15 scalpel
(see FIGS 3 to 8) and Colorado-tipped Bovie electrocautery to address the
regions of the mandible requiring fixation.
■ Anatomically reduce and stabilize the mandible with the appropriately sized
surgical reconstruction kit placed in a bicortical manner to avoid vital
structures.
■ The use of monocortical screws and a “simplification” plate may be
necessary to assist with temporary stabilization of the mandibular fracture.
■ Impressions for dental splints should be accomplished only after the
establishment of a stable dentoalveolar table of at least one dental arch.
■ Access to the maxilla is achieved with a combination of a no. 15 scalpel and
Colorado-tipped Bovie electrocautery.
■ The incision is made approximately 5 to 7 mm superior to the junction of
the attached gingiva and alveolar mucosa to reduce maxillary fractures for
the establishment of a functional occlusion.
■ The patient’s occlusion is established with intermaxillary/maxillomandibular

fixation.
■ Stabilization of the maxillary fractures is then performed.
■ A coronal incision is performed with a no. 15 scalpel and Colorado-tipped
Bovie electrocautery to gain access to the zygomatic arches/frontal bar
bilaterally.
Video p2-c073_02
Video p2-c073_03
■ Reduction/stabilization of the zygomatic arch fractures is accomplished, as
well as any frontal bar/frontal sinus fractures.
00:00 / 00:00
00:00 / 00:00

Video p2-c073_04
■ Repair of orbital floor fractures is accomplished.
■ Repair of NOE fractures is accomplished.
■ Intraoperative CT scanning (if available) is obtained at this time to evaluate
reduction and fixation.
■ Facial soft tissues are resuspended (TECH FIG 1C).
■ Closure of incisions (TECH FIG 1D)
■ Top-to-Bottom Approach
■ A coronal incision is performed with a no. 15 scalpel and Colorado-tipped
Bovie electrocautery to gain access to the zygomatic arches and frontal bar
bilaterally.
■ Reduction with stabilization of the zygomatic arch, zygoma, and any frontal
bar and frontal sinus fractures is completed.
■ Repair of NOE fractures is accomplished.
■ Repair of orbital floor fractures is performed.
■ Erich arch bars are adapted to the maxilla and mandible and secured with 24-
gauge stainless steel wires.
■ Placement of the arch bars should begin on one side and progress laterally,
incorporating all of the dentition.
■ The arch bars are malleable, and simultaneous placement of the arch bars
from the bilateral posterior region results in “excess” material, which
classically prevents incorporation of the anterior dentition.
00:00 / 00:00

■ Bone-anchored arch bars can be considered for dental arches that do not
have disruption of the dentoalveolar tables.
■ Access to the mandible is achieved with a combination of a no. 15 scalpel
and Colorado-tipped Bovie electrocautery to address the regions of the
mandible requiring fixation (see FIGS 3 to 8).
■ Anatomically reduce and stabilize the mandible with the appropriate-sized
surgical reconstruction kit placed preferably in a bicortical manner to avoid
vital structures.
■ The use of monocortical screws and a “simplification” plate may be
necessary to assist with temporary stabilization of the mandibular fracture.
■ Impressions for dental splints should be accomplished only after the
establishment of a stable dentoalveolar table of at least one dental arch.
■ Access to the maxilla is achieved with a combination of a no. 15 scalpel and
Colorado-tipped Bovie electrocautery via an incision approximately 5 to 7
mm superior to the junction of the attached gingiva and alveolar mucosa.
■ This is to address the regions of the maxilla requiring reduction of
maxillary fractures for establishing a functional occlusion.
■ The patient’s occlusion is established with intermaxillary/maxillomandibular
fixation.
■ Stabilization of the maxillary level fractures is performed.
■ Intraoperative CT scanning (if available) is obtained at this time to evaluate
reduction/fixation.
■ Facial soft tissues are resuspended.
■ Closure of incisions
■ Bottom-to-Top-to-Middle Approach
■ Erich arch bars are adapted to the maxilla and mandible and secured with 24-
gauge stainless steel wires.
■ Placement of the arch bars should only begin on one side and progress
laterally incorporating all of the dentition.
■ The arch bars are malleable, and simultaneous placement of the arch bars
from the bilateral posterior region results in “excess” material that
classically prevents incorporation of the anterior dentition.
■ Bone-anchored arch bars can be considered for dental arches that do not
have disruption of the dentoalveolar tables.

■ A no.15 scalpel and Colorado-tipped Bovie electrocautery can be used to
access the regions of the mandible requiring fixation (see FIGS 3 to 8).
■ Anatomically reduce/stabilize the mandible with the appropriate sized
surgical reconstruction kit placed preferably in a bicortical manner should
this avoid vital structures.
■ The use of monocortical screws and a “simplification” plate may be
necessary to assist with temporary stabilization of the mandibular fracture.
■ Impressions for dental splints should be accomplished only after the
establishment of a stable dentoalveolar table of at least one dental arch.
■ Access to the maxilla is achieved with a combination of a no. 15 scalpel and
Colorado-tipped Bovie electrocautery via an incision approximately 5 to 7
mm superior to the junction of the attached gingiva and alveolar mucosa.
This treats the regions of the maxilla requiring reduction of maxillary
fractures for the establishment of a functional occlusion.
■ The patient’s occlusion is established with intermaxillary/maxillomandibular
fixation.
■ A coronal incision is performed with a no. 15 scalpel and Colorado-tipped
Bovie electrocautery to gain access to the zygomatic arches/frontal bar region
bilaterally.
■ Reduction/stabilization of the zygomatic arch fractures is accomplished, as
well as any frontal bar/frontal sinus fractures.
■ Repair of orbital fractures is accomplished.
■ Repair of NOE fractures is accomplished.
■ Maxillary level fractures are stabilized.
■ Intraoperative CT scanning (if available) is obtained at this time to evaluate
reduction/fixation.
■ Facial soft tissues are resuspended.
■ Layered closure is undertaken, including interrupted absorbable suture
material for deep and dermal layers and nonabsorbable interrupted closure for
skin.
PEARLS AND PITFALLS
Preoperative radiology
■ Comprehensive CT scans with 3D reconstruction

should be obtained for presurgical planning on all
panfacial trauma patients.
Exposure
■ Adequate exposure for visualization of all
fractures is critical for anatomic reduction.
Subunit principle of repair
■ Repair the cranio-orbital subunit independent of
the lower face and the maxillomandibular subunit
independent of the upper face.
Ptosis of soft tissues
■ Lack of resuspension of the facial soft tissues
after skeletonizing the calvarium for access to the
fractures results in ptosis of the fat pads of the
face and premature facial aging.
Reliance on dental splints
without a stable skeletal
foundation (either
anatomically reduced
maxilla/mandible)
■ Because of normal variability in dental occlusion,
the lack of a stable arch form for reconstruction
frequently results in loss of AP projection of the
face and the classic appearance of a flat, wide
midface.
Interval/intraoperative CT
scans
■ Critically determine the proper alignment and
stabilization of the facial structures during
complex reconstruction.
Postoperative review of
radiology
■ 3D CT scans should be evaluated in the
immediate postoperative period to determine the
need for potential early intervention to correct
issues of enophthalmos, inadequate reduction, or
poor stabilization.

FIG 9 • Postoperative review of midfacial (A) and
mandibular (B) reconstruction.
POSTOPERATIVE CARE
■ If intraoperative CT scanning was not accomplished to review the reduction
and fixation of fractures, comprehensive radiographic evaluation is performed
in the immediate postoperative period in order to determine any potential need
for revision (FIG 9).
■ Daily checks are necessary while the patient is hospitalized; weekly outpatient
checks should be performed until intermaxillary/maxillomandibular fixation
has been discontinued and arch bars have been removed. Continue to reinforce
the importance of oral hygiene.
■ Physical therapy for active range of motion is frequently needed.
■ Upon optimization of skeletal alignment and scar maturation (typically after 1
year), revision of soft tissue injuries may be undertaken.
OUTCOMES
■ Gutta et al.6 performed a 5-year analysis of postoperative outcomes in patients
who received treatment for mandibular fractures:
■ In a cohort of 363 patients, the overall complication rate was 26%, with
hardware failure and infection being the two most common complications.

■ Patel et al.7 found that methods of fixation, such as the Champy technique and
use of reconstruction plates, were associated with higher rates of bony union
and patient comfort.
■ Extraction vs retention of teeth in the line of fracture has not been shown to
significantly impact the outcome of reconstruction.
■ A critical review of the literature, coupled with an internal review of more than
1200 facial fracture cases managed at our institution over a 6-year period,
suggests that most complications encountered are secondary to operator error,
either in decision-making/judgment or in technical performance.
■ Rigidly stabilizing a fracture in a nonanatomic position resulting in
malocclusion is not a failure of the hardware, nor should the surgeon expect
the malocclusion to spontaneously correct.
■ Selecting an inappropriate type/size of surgical plate for fracture repair
without an understanding of the functional load the plate is subjected to
should not be considered hardware failure if the plate loosens or breaks.
■ Inadequate intraoral/extraoral closure of the surgical access or wound, with
resulting exposure of the surgical hardware, is not truly a hardware
complication.8
■ In a single-center retrospective review of 359 patients who underwent surgical
management of facial fractures, specific mechanisms of injury (such as MVC)
and concomitant tobacco, alcohol, and/or tobacco use were associated with
higher rates of surgical site infections.9
COMPLICATIONS
■ Nonunion
■ Malocclusion
■ Asymmetry/soft tissue ptosis
■ Soft tissue scarring
■ Narrowing or overwidening of the face
■ Lid malposition
ACKNOWLEDGMENT
We thank Visakha Suresh, BSE, BS, for her valuable contribution to the
preparation of this chapter.
REFERENCES
1. Erdmann D, Follmar KE, Debruijn M, et al. A retrospective analysis of facial

fracture etiologies. Ann Plast Surg. 2008;60:398-403.
2. Back CP, McLean NR, Anderson PJ, David DJ. The conservative management
of facial fractures: indications and outcomes. J Plast Reconstr Aesthet Surg.
2007;60:146-151.
3. Gruss JS, Van Wyck L, Phillips JH, Antonyshyn O. The importance of the
zygomatic arch in complex midfacial fracture repair and correction of
posttraumatic orbitozygomatic deformities. Plast Reconstr Surg. 1990;85:878-
890.
4. Hönig JF, Merten HA, Wiltfang J. Avoidance of implicit hazards: the
realignment of maxillary and mandibular arches in comminuted and facial
fractures. J Craniofac Surg. 1998;9:514-521.
5. Tang W, Fen F, Long J, et al. Sequential surgical treatment for panfacial
fractures and significance of biological osteosynthesis. Dent Traumatol.
2009;25:171-175.
6. Gutta R, Tracy K, Johnson C, et al. Outcomes of mandible fracture treatment
at an academic tertiary hospital: a 5-year analysis. J Oral Maxillofac Surg.
2014;72:550-558.
7. Patel N, Kim B, Zaid W. A detailed analysis of mandibular angle fractures:
epidemiology, patterns, treatments, and outcomes. J Oral Maxillofac Surg.
2016;74:1792-1799.
8. Moses H, Powers D, Keeler J, et al. Opportunity cost of surgical management
of craniomaxillofacial trauma. Craniomaxillofac Trauma Reconstr. 2016;8:76-
81.
9. Domingo F, Dale E, Groves C, et al. A single-center retrospective review of
post-operative infectious complications in the surgical management of
mandibular fractures: post-operative antibiotics add no benefit. J Trauma Acute
Care Surg. 2016;81: 1109-1114.

74
CHAPTER
Section XIII: Pediatric
Trauma
Pediatric Orbital Fractures
James Y. Liau
DEFINITION
■ Fractures of the inferior and/or medial orbital wall
ANATOMY
■ The orbit consists of seven bones; however, the ones that are involved are
invariably the maxilla and ethmoid bones. Operative repair focuses on re-
establishing the appropriate volume of these components (FIG 1A).
■ Other pertinent anatomy includes optic nerve and superior fissure, which
contains CN III to CN VI. These structures are located in the superior medial
aspect of the orbit (FIG 1B).
■ Soft tissue anatomy is relevant. This includes the palpebral fissure, gray lash
line, septum, canthus, and caruncula (FIG 1C).
■ Usually, orbital growth is complete by 6 to 8 years of age.
PATHOGENESIS
■ Inferior orbital floor fractures occur with facial trauma, which entails a blow to
the globe resulting in increased orbital pressure. This pressure fractures the
thinner maxillary portion of the orbital floor causing a blow-out fracture into
the maxillary sinus.
NATURAL HISTORY
■ Diplopia that is self-limiting
■ Enophthalmos can occur if the orbital volume is not corrected with floor
reconstruction or soft tissue volume atrophy from trauma.

■ Entrapment results in muscle fibrosis and permanently impaired conjugate
gaze.1
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Because of immediate post-traumatic swelling, enophthalmos is usually not
appreciated clinically until swelling has decreased, unless the orbital blow-out
fracture is quite large. Then enophthalmos and dystopia may be immediately
appreciated.
■ With blow-out fractures, extraocular movements are usually decreased due to
the trauma and swelling, but there is usually some degree of movement.
■ With entrapment, there is no voluntary extraocular movement due to pain.
Attempted upward gaze will result in intense pain, and nausea; bradycardia can
also occur.
IMAGING
■ CT scan is the modality of choice. All three views are essential.
■ Axial views elucidate whether there is medial wall involvement, and the size.
■ Coronal views elucidate the width of floor fracture, medial wall, inferior
rectus muscle involvement, and inferior orbital nerve involvement.
■ Sagittal views elucidate the length of the floor fracture and inferior rectus
muscle involvement and helps delineate the depth of the dissection before
encountering the posterior shelf.
DIFFERENTIAL DIAGNOSIS
■ Need to diagnose other concomitant facial fractures. Most commonly involved
are
■ Medial wall
■ Zygomatic maxillary complex
■ Le Fort 2
■ Le Fort 3
NONOPERATIVE MANAGEMENT
■ Conservative treatment runs a higher risk of enophthalmos depending on the
size of fracture. Amblyopia in pediatric population is generally self-limiting
due to the adaptable plasticity of the brain.
SURGICAL MANAGEMENT

Preoperative Planning
■ Performing CT scan of axial, coronal, and sagittal planes will help clarify
anatomy such as orbital content or inferior rectus entrapment (FIG 2).
■ Forced duction test under anesthesia if concerned about entrapment. This is
difficult to do in an awake patient due to pain despite topical anesthetic drops.
I usually defer to CT scan and clinical physical examination of pain and nausea
with or without bradycardia upon upward gaze.
Types of Implants
■ Synthetic
■ Polyethylene
• Pros: No donor site and easily cut to size
• Cons: Does not “grow” with the child, extrusion if not secured adequately,
can become infected, and does not have rigidity for adequate support
required in extensive orbital floor fracture
■ Titanium
• Pros: Easily obtainable, retains shape, and easily cut to size, excellent
rigidity required for extensive orbital fractures
• Cons: Does not grow with child, extrusion if not secured adequately,
concerns of soft tissue tethering into the openings of the implant1,2

FIG 1 • A. Pediatric skull demonstrating the size of the
orbit and forehead compared to the rest of the body.
Orbital bones are labeled demonstrating the complexity
of the orbital cone. B. Pediatric skull demonstrating the
size of the superior fissure and the optic foramen in
relation to the rest of the orbital cone. Note the size of
the superior fissure in proportion to the rest of the
orbital cone, as well as its location superomedially. This
needs to be taken into account when dissecting on the
floor. C. Pediatric eye demonstrating the soft tissue
anatomy relevant for orbital fracture surgical exposure.
■ Mixed
• Pros: Easily obtainable and has both rigidity and minimal risk of tethering at

implant/soft tissue interface
• Cons: Does not grow with child; risk of extrusion if not secured adequately
■ Autologous
■ Bone
• Pros: Autologous; can be easily shaped
• Cons: Donor-site morbidity; requires time for harvest
■ Cartilage
• Pros: Autologous; can be easily shaped
• Cons: Donor-site morbidity; requires time for harvest
Positioning
■ Need to be able to stand at head of bed allowing 270-degree access to the
head. Usually turning the bed 90 degrees or 180 degrees provides this access
(FIG 3A).
■ Shoulder roll extending the head to give better visualization of the orbital floor
(FIG 3B,C).
Approach
■ Surgical treatment of orbital fracture can be separated into two different
stages. Stage one is the soft tissue exposure and closure, and stage two is the
orbital bone repair. Meticulous attention to detail is needed for the soft tissue
handling during the exposure and closure because inadequate soft tissue
handling can result in severe complications potentially worse than
nontreatment. In fact, the actual soft tissue approach can be more morbid than
the injury; refined handling of soft tissue is essential for favorable outcomes.3